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Grunwell JR, Mutic AD, Ezhuthachan ID, Mason C, Tidwell M, Caldwell C, Norwood J, Zack S, Jordan N, Fitzpatrick AM. Environmental Injustice Is Associated With Poorer Asthma Outcomes in School-Age Children With Asthma in Metropolitan Atlanta, Georgia. J Allergy Clin Immunol Pract 2024; 12:1263-1272.e1. [PMID: 38378096 PMCID: PMC11081836 DOI: 10.1016/j.jaip.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/10/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Environmental justice mandates that no person suffers disproportionately from environmental exposures. The Environmental Justice Index (EJI) provides an estimate of the environmental burden for each census tract but has not yet been used in asthma populations. OBJECTIVE We hypothesized that children from census tracts with high environmental injustice determined by the EJI would have a greater burden of asthma exacerbations, poorer asthma control, and poorer lung function over 12 months. METHODS Children aged 6 to 18 years with asthma (N = 575) from metropolitan Atlanta, Georgia, completed a baseline research visit. Participant addresses were geocoded to obtain the EJI Social-Environmental Ranking for each participant's census tract, which was divided into tertiles. Medical records were reviewed for 12 months for asthma exacerbations. A subset of participants completed a second research visit involving spirometry and questionnaires. RESULTS Census tracts with the greatest environmental injustice had more racial and ethnic minorities, lower socioeconomic status, more hazardous exposures (particularly to airborne pollutants), and greater proximity to railroads and heavily trafficked roadways. Children with asthma residing in high injustice census tracts had a longer duration of asthma, greater historical asthma-related health care utilization, poorer asthma symptom control and quality of life, and more impaired lung function. By 12 months, children from high injustice census tracts also had more asthma exacerbations with a shorter time to exacerbation and persistently more symptoms, poorer asthma control, and reduced lung function. CONCLUSIONS Disparities in environmental justice are present in metropolitan Atlanta that may contribute to asthma outcomes in children. These findings require an additional study and action to improve health equity.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - Idil D Ezhuthachan
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Allergy and Immunology, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Carrie Mason
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Mallory Tidwell
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Cherish Caldwell
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jalicae Norwood
- Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Sydney Zack
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Natalie Jordan
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
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Fitzpatrick AM, Kavalieratos D, Vickery BP, Lee T, Mason C, Grunwell JR. Altered Symptom Perception in Children With Asthma Is Associated With Poor Childhood Opportunity and Adverse Outcomes. The Journal of Allergy and Clinical Immunology: In Practice 2024; 12:983-990. [PMID: 38142865 PMCID: PMC10999352 DOI: 10.1016/j.jaip.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/12/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Effective asthma self-management requires that children recognize their asthma symptoms when they occur. However, some children have altered symptom perception, which impairs their ability to respond to their asthma symptoms in a timely manner. OBJECTIVE To characterize the prevalence and features of altered symptom perception in children aged 5 to 18 years. We hypothesized that children with altered symptom perception would have more features of uncontrolled asthma, more health inequity, and poorer longitudinal asthma outcomes over 12 months. METHODS Children (N = 371) completed an outpatient research visit for clinical characterization. Altered symptom perception was defined by discordance between child responses on the 6-item Asthma Control Questionnaire and medical provider-elicited symptoms. Electronic medical records were reviewed for 12 months for the occurrence of an asthma exacerbation treated with systemic corticosteroids and an asthma exacerbation prompting an emergency department visit. RESULTS Approximately 15% of children had altered symptom perception and their asthma features were similar to those of children with uncontrolled asthma. Children with altered symptom perception were uniquely distinguished by non-White race and more severe prior exacerbations. These children also resided in ZIP codes with the poorest childhood opportunity (ie, poorest education, health and environmental features, and socioeconomic features). Outcomes of children with altered symptom perception were equally disparate with approximately 2-fold higher odds of a future exacerbation and approximately 3-fold higher odds of an emergency department visit for asthma. CONCLUSIONS Altered symptom perception is present in a small but significant number of children with asthma and is related to poorer childhood opportunity and other health inequities that require additional intervention.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Dio Kavalieratos
- Department of Pediatrics, Emory University, Atlanta, Ga; Department of Family and Preventative Medicine, Emory University, Atlanta, Ga
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | - Tricia Lee
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. J Allergy Clin Immunol Pract 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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Schwarz T, Schmidt AE, Bobek J, Ladurner J. Barriers to accessing health care for people with chronic conditions: a qualitative interview study. BMC Health Serv Res 2022; 22:1037. [PMID: 35964086 PMCID: PMC9375930 DOI: 10.1186/s12913-022-08426-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 08/05/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is a growing interest in redesigning healthcare systems to increase access to and coordination across care settings for people with chronic conditions. We aim to gain a better understanding of the barriers faced by (1) children with chronic bronchial asthma, (2) adults with non-specific chronic back pain, and (3) older people with pre-existing mental illness/es in Austria's fragmented social health insurance system. METHODS Using a qualitative design, we conducted semi-structured interviews face-to-face and by telephone with health service providers, researchers, experts by experience (persons with lived/ personal experience, i.e., service users, patient advocates or family members/carers), and employees in public health administration between July and October 2019. The analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework used to evaluate access broadly according to different dimensions of accessibility to care: approachability, acceptability, availability and accommodation, affordability, and appropriateness. RESULTS The findings from the 25 expert interviews were organised within Levesque's conceptual framework. They highlight a lack of coordination and defined patient pathways, particularly at the onset of the condition, when seeking a diagnosis, and throughout the care process. On the supply side, patterns of poor patient-provider communication, lack of a holistic therapeutic approach, an urban-rural divide, strict separation between social care and the healthcare system and limited consultation time were among the barriers identified. On the demand side, patients' ability to perceive a need and to subsequently seek and reach healthcare services was an important barrier, closely linked to a patient's socio-economic status, health literacy and ability to pay. CONCLUSIONS While studies on unmet needs suggest a very low level of barriers to accessing health care in the Austrian context, our study highlights potential 'invisible' barriers. Barriers to healthcare access are of concern for patients with chronic conditions, underlining existing findings about the need to improve health services according to patients' specific needs. Research on how to structure timely and integrated care independent of social and economic resources, continuity of care, and significant improvements in patient-centred communication and coordination of care would be paramount.
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Affiliation(s)
- Tanja Schwarz
- Austrian National Public Health Institute, Addiction Competence Centre, Stubenring 6, 1010, Vienna, Austria
| | - Andrea E Schmidt
- Austrian National Public Health Institute, Competence Centre on Climate and Health, Stubenring 6, 1010, Vienna, Austria.
| | - Julia Bobek
- Austrian National Public Health Institute, Health Economics and Health Systems Analysis, Stubenring 6, 1010, Vienna, Austria
| | - Joy Ladurner
- Austrian National Public Health Institute, Psychosocial Health, Stubenring 6, 1010, Vienna, Austria
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Bryant-Stephens T, Williams Y, Kanagasundaram J, Apter A, Kenyon CC, Shults J. The West Philadelphia asthma care implementation study (NHLBI# U01HL138687). Contemp Clin Trials Commun 2021; 24:100864. [PMID: 34926863 PMCID: PMC8649219 DOI: 10.1016/j.conctc.2021.100864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 11/28/2022] Open
Abstract
Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.
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Key Words
- ACQ, Asthma Control Questionnaire
- Asthma
- Asthma in children
- CAPP, Communitiy Asthma Prevention Program
- CHOP, Children's Hospital of Philadelphia
- CHW, Community Health Worker
- Community research
- EBI, Evidence-based intervention
- ED, emergency department
- EHR, electronic health record
- IRB, institutional review board
- Implementation science
- OAS, Open Airways for Schools
- SAMPRO, School-based Asthma Management Program
- SBAT, School-based Asthma Therapy
- WEPACC, West Philadelphia Asthma Care Collaborative
- pCHW, primary care community health worker
- sCHW, school-based community health worker
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Affiliation(s)
- Tyra Bryant-Stephens
- Community Asthma Prevention Program, Sr Director, Center for Health Equity, Associate Professor of Pediatrics, United States
| | | | | | - Andrea Apter
- Perelman School of Medicine at the University of Pennsylvania, United States
| | - Chén C. Kenyon
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Justine Shults
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States
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Fitzpatrick AM, Chipps BE, Holguin F, Woodruff PG. T2-"Low" Asthma: Overview and Management Strategies. J Allergy Clin Immunol Pract 2021; 8:452-463. [PMID: 32037109 DOI: 10.1016/j.jaip.2019.11.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023]
Abstract
Although the term "asthma" has been applied to all patients with airway lability and variable chest symptoms for centuries, phenotypes of asthma with distinct clinical and molecular features that may warrant different treatment approaches are well recognized. Patients with type 2 (T2)-"high" asthma are characterized by upregulation of T2 immune pathways (ie, IL-4 and IL-13 gene sets) and eosinophilic airway inflammation, whereas these features are absent in patients with T2-"low" asthma and may contribute to poor responsiveness to corticosteroid treatment. This review details definitions and clinical features of T2-"low" asthma, potential mechanisms and metabolic aspects, pediatric considerations, and potential treatment approaches. Priority research questions for T2-"low" asthma are also discussed.
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Affiliation(s)
| | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Fernando Holguin
- University of Colorado, Pulmonary Sciences and Critical Care Medicine, Denver, Colo
| | - Prescott G Woodruff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, and the Cardiovascular Research Institute, University of California, San Francisco, Calif
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Shah SN, Grunwell JR, Mohammad AF, Stephenson ST, Lee GB, Vickery BP, Fitzpatrick AM. Performance of Eosinophil Cationic Protein as a Biomarker in Asthmatic Children. J Allergy Clin Immunol Pract 2021; 9:2761-2769.e2. [PMID: 33781764 DOI: 10.1016/j.jaip.2021.02.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/07/2021] [Accepted: 02/25/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although blood eosinophils are a frequently used marker of type 2 inflammation in children with asthma, their sensitivity is relatively poor. Additional markers of type 2 inflammation are needed. OBJECTIVE We hypothesized that plasma concentrations of eosinophil cationic protein (ECP), a marker of eosinophil activation, would be useful for detection of type 2 inflammation and would predict poorer asthma outcomes over 1 year. METHODS Children and adolescents 6 through 17 years (N = 256) with confirmed asthma completed a baseline visit and a follow-up visit at 12 months. A subset also underwent systemic corticosteroid responsiveness testing with intramuscular triamcinolone. Outcome measures at 12 months included uncontrolled asthma, lung function, and asthma exacerbations treated with systemic corticosteroids. RESULTS Plasma ECP concentrations ranged from 0.03 to 413.61 ng/mL (median, 6.95 ng/mL) and were consistently associated with other markers of type 2 inflammation. At baseline, children in the highest ECP tertile had poorer asthma control, more airflow limitation, and more exacerbations, but also had greater symptom improvement with intramuscular triamcinolone. At 12 months, associations between the highest ECP tertile and exacerbations, but not lung function or asthma control, persisted after covariate adjustment. However, the sensitivity of ECP was modest and was not markedly different from that of blood eosinophil counts. CONCLUSION Plasma ECP concentrations may be a useful marker of type 2 inflammation in children and may help identify those children at highest risk for recurrent exacerbations who could benefit from corticosteroid treatment. However, additional markers may be needed to improve sensitivity for outcome detection.
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Affiliation(s)
- Sheel N Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | | | - Gerald B Lee
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Ashok N, Kirubakaran R, Saraswathy R. Association of vitamin D gene polymorphisms in children with asthma - A systematic review. Heliyon 2020; 6:e04795. [PMID: 32939414 PMCID: PMC7479342 DOI: 10.1016/j.heliyon.2020.e04795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 06/23/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The association of Vitamin D and children with asthma is known and there are several individual studies on Vitamin D polymorphisms. However, systematic reviews on all vitamin D associated gene polymorphisms have not been done in children with asthma. OBJECTIVE To investigate the association of Vitamin D associated gene polymorphisms and asthma in children (0-18 years) by systematic review and meta-analytic approach. METHODS Our search included 20 full text articles of which 15 were case control studies and 5 used family based linkage disequilibrium method. Total of 2491cases and 3682 controls were included in case control studies, with mean age of 9.58 years and 10.16 years respectively. Quantitative and qualitative analysis were done. RESULTS Quantitative analysis revealed significant association with protective effect of Apa1 polymorphism in allele (OR 0.81 (0.71,0.91) and homozygous major form (OR 0.83 (0.70,0.98) and Taq 1 minor allele in homozygous form (OR 0.73 (0.58,0.92) in children with asthma. However, the minor allele of Apa1(OR 1.21 (1.07,1.37), Bsm 1 in heterozygous (OR 1.35 (1.07,1.71) and homozygous minor form (OR 1.95 (1.59,2.39), major allele of Fok1(OR1.34 (1.17,1.52) and Taq1 (OR 1.22 (1.08,1.38) were found to be increasing the odds of asthma. Ethnic variations were noted in subgroup analysis. Qualitative analysis of the polymorphisms of the Vitamin D associated metabolic genes also showed significant associations. CONCLUSION Our review shows significant associations with VDR polymorphisms - Apa1, Bsm1, Fok 1, Taq 1, polymorphisms of Vitamin D metabolic genes - CYP27A1, CYP 2R1, CYP 24A1, GC and genes related to Vitamin D response element (VDRE) in children with asthma. Conducting large studies involving various ethnic regions will strengthen our knowledge on the association and aid in targeted interventions for control of asthma in children.
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Affiliation(s)
- Narmada Ashok
- School of Biosciences & Technology, VIT University, Vellore
- Nalam Medical Centre & Hospital, Vellore
| | | | - Radha Saraswathy
- 120TT Biomedical Genetics Research Lab (BMGRL), Dept of Biomedical Sciences, School of Biosciences & Technology, VIT University 632014, Vellore
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Grunwell JR, Gillespie S, Morris CR, Fitzpatrick AM. Latent Class Analysis of School-Age Children at Risk for Asthma Exacerbation. J Allergy Clin Immunol Pract 2020; 8:2275-2284.e2. [PMID: 32198127 DOI: 10.1016/j.jaip.2020.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/07/2020] [Accepted: 03/01/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Factors responsible for asthma exacerbations in children are complex and may differ from those that drive asthma severity. OBJECTIVE To identify latent classes of children at risk for asthma exacerbation and determine whether latent class assignment is useful in the prediction of future exacerbation. METHODS Latent class analysis was performed on 513 children aged 6 to 17 years at risk for asthma exacerbation, with 31 variables encompassing demographics, medical history, treatment, symptoms, lung function, sensitization, and type 2 inflammation. Primary and secondary outcomes included exacerbation occurrence by 12 months and time to first exacerbation, respectively. RESULTS Four latent classes were identified with differing demographic features, sensitization and type 2 inflammatory markers, prior exacerbation severity and health care utilization, and lung function. Exacerbations occurred in 22.4% of class 1 ("lesser sensitization with normal lung function"), 27.9% of class 2 ("lesser sensitization with prior severe exacerbation and normal lung function"), 45.3% of class 3 ("multiple sensitization with reversible airflow limitation"), and 64.3% of class 4 ("multiple sensitization with partially reversible airflow limitation") (P < .001). Time to exacerbation also followed similar trends and was shortest in the latent classes with multiple sensitization and airflow limitation (P < .001). Outcomes were driven largely by children with exacerbation-prone asthma (defined as ≥3 exacerbations in the prior year), who were present in each class but most strongly represented in classes 3 and 4. CONCLUSIONS Children at risk for asthma exacerbation are a heterogeneous group. Sensitization, prior exacerbation severity, and lung function variables may be particularly useful in identifying children at greatest risk for future exacerbation.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Clinical and Translational Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Claudia R Morris
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Clinical and Translational Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Clinical and Translational Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Fitzpatrick AM, Bacharier LB, Jackson DJ, Szefler SJ, Beigelman A, Cabana M, Covar R, Guilbert T, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Raissy HH, Zeiger RS, Mauger DT. Heterogeneity of Mild to Moderate Persistent Asthma in Children: Confirmation by Latent Class Analysis and Association with 1-Year Outcomes. J Allergy Clin Immunol Pract 2020; 8:2617-2627.e4. [PMID: 32156610 DOI: 10.1016/j.jaip.2020.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Compared with adults, phenotypic characterization of children with asthma is still limited and it remains difficult to predict which children with asthma are at highest risk for poor outcomes. OBJECTIVE To identify latent classes in a large population of treatment-adherent children with mild to moderate asthma enrolled in clinical trials and determine whether latent class assignment predicts future lung function abnormalities and exacerbation rate. METHODS Latent class analysis was performed on 2593 children with mild to moderate asthma aged 5 18 years, with 19 variables encompassing demographic characteristics, medical history, symptoms, lung function, allergic sensitization, and type 2 inflammation. Outcomes included lung function and the annualized exacerbation rate at 12 months of follow-up. RESULTS Five latent classes were identified with differing demographic features, asthma control, sensitization, type 2 inflammatory markers, and lung function. Exacerbation rates were 1.30 ± 0.12 for class 1 (multiple sensitization with partially reversible airflow limitation), 0.90 ± 0.05 for class 2 (multiple sensitization with reversible airflow limitation), 0.87 ± 0.08 for class 3 (lesser sensitization with reversible airflow limitation), 0.87 ± 0.05 for class 4 (multiple sensitization with normal lung function), and 0.71 ± 0.06 for class 5 (lesser sensitization with normal lung function). Lung function abnormalities persisted in class 1 at 12 months. CONCLUSIONS Children with mild to moderate asthma are a heterogeneous group. Allergic sensitization and lung function may be particularly useful in identifying children at the greatest risk for future exacerbation. Additional studies are needed to determine whether latent classes correspond to meaningful phenotypes for the purpose of personalized treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Daniel J Jackson
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Stanley J Szefler
- Children's Hospital Colorado and Department of Pediatrics, University of Colorado, Aurora, Colo
| | - Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Michael Cabana
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York, NY
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Theresa Guilbert
- Department of Pediatrics, University of Cincinnati and Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio
| | | | - Robert F Lemanske
- Departments of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | | | - Wayne Morgan
- Department of Pediatrics, The University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital and Harvard Medical School Department of Pediatrics, Boston, Mass
| | | | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region and Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Public Health Sciences, Penn State University, Hershey, Pa
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11
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Grunwell JR, Nguyen KM, Bruce AC, Fitzpatrick AM. Bronchodilator Dose Responsiveness in Children and Adolescents: Clinical Features and Association with Future Asthma Exacerbations. J Allergy Clin Immunol Pract 2019; 8:953-964. [PMID: 31614217 DOI: 10.1016/j.jaip.2019.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/20/2019] [Accepted: 09/23/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Bronchodilator reversibility measures are often associated with poor asthma outcomes in children. Whether bronchodilator dose responsiveness is similarly useful in children is unclear. OBJECTIVE We hypothesized that children and adolescents requiring higher doses of bronchodilator to achieve maximal bronchodilation would have unique risk factors and increased risk of future exacerbation. METHODS Children (6-11 years, N = 299) and adolescents (12-21 years, N = 331) with confirmed asthma underwent clinical phenotyping procedures and a test of maximal bronchodilation with escalating doses of albuterol sulfate up to 720 mcg. Outcome measures were assessed at 12 months and included exacerbations treated with systemic corticosteroids, emergency department (ED) visits, and hospitalizations for asthma. RESULTS A total of 6.7% of children and 9.3% of adolescents had poor bronchodilator dose responsiveness, defined as attainment of maximal forced expiratory volume in 1 second with 720 mcg albuterol. Risk factors included type 2 inflammation, prior exacerbations, and greater asthma severity; historical pneumonia and tobacco exposure were also risk factors in children. Children and adolescents with poor bronchodilator dose responsiveness did not have increased current symptoms or impaired quality of life, but had approximately 2-fold increased odds of exacerbation or ED visit and approximately 3-fold increased odds of hospitalization by 12 months, independent of airflow obstruction. CONCLUSIONS Bronchodilator dose responsiveness may be useful for phenotyping and may be of utility in practice and future studies focused on asthma outcomes or quantification of treatment responses. In children and adolescents, this phenotype of poor bronchodilator responsiveness may be associated with periods of relatively stable disease yet marked airway constriction in response to triggers, including tobacco smoke, respiratory infections/pneumonia, and aeroallergens.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Alice C Bruce
- Department of Pediatrics, Emory University, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
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Fitzpatrick AM, Bacharier LB, Guilbert TW, Jackson DJ, Szefler SJ, Beigelman A, Cabana MD, Covar R, Holguin F, Lemanske RF, Martinez FD, Morgan W, Phipatanakul W, Pongracic JA, Zeiger RS, Mauger DT. Phenotypes of Recurrent Wheezing in Preschool Children: Identification by Latent Class Analysis and Utility in Prediction of Future Exacerbation. J Allergy Clin Immunol Pract 2018; 7:915-924.e7. [PMID: 30267890 DOI: 10.1016/j.jaip.2018.09.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recurrent preschool wheezing is a heterogeneous disorder with significant morbidity, yet little is known about phenotypic determinants and their impact on clinical outcomes. OBJECTIVE Latent class analysis (LCA) was used to identify latent classes of recurrent preschool wheeze and their association with future exacerbations and inhaled corticosteroid (ICS) treatment response. METHODS Data from 5 clinical trials of 1708 children aged 12 to 71 months with recurrent wheezing were merged. LCA was performed on 10 demographic, exposure, and sensitization variables to determine the optimal number of latent classes. The primary outcome was the annualized rate of wheezing exacerbations requiring systemic corticosteroids during the study intervention period; the secondary outcome was the time to first exacerbation. Exploratory analyses examined the effect of daily ICS treatment on exacerbation outcomes. RESULTS Four latent classes of recurrent wheezing were identified; these were not distinguished by current symptoms or historical exacerbations but differed with regard to allergen sensitization and/or exposures. Annualized exacerbation rates (mean ± SEM/year) were 0.65 ± 0.06 for class 1 ("minimal sensitization"), 0.93 ± 0.10 for class 2 ("sensitization with indoor pet exposure"), 0.60 ± 0.07 for class 3 ("sensitization with tobacco smoke exposure"), and 0.81 ± 0.10 for class 4 ("multiple sensitization and eczema") (P < .001). In a research setting of high adherence, daily ICS treatment improved exacerbation rates in classes 2 and 4 but not the other groups. CONCLUSIONS Sensitization and exposure assessments are useful in the prediction of future exacerbation and may identify children most likely to respond favorably to daily ICS treatment.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | | | - Theresa W Guilbert
- Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | | | - Stanley J Szefler
- Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado, Aurora, Colo
| | | | - Michael D Cabana
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Ronina Covar
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Fernando Holguin
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pa
| | | | | | - Wayne Morgan
- Department of Pediatrics, University of Arizona, Tucson, Ariz
| | - Wanda Phipatanakul
- Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | | | - Robert S Zeiger
- Kaiser Permanente, Southern California Region, San Diego, Calif; Department of Pediatrics, University of California San Diego, San Diego, Calif
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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Bergfors S, Åström M, Burström K, Egmar AC. Measuring health-related quality of life with the EQ-5D-Y instrument in children and adolescents with asthma. Acta Paediatr 2015; 104:167-73. [PMID: 25393977 DOI: 10.1111/apa.12863] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/07/2014] [Accepted: 09/08/2014] [Indexed: 11/28/2022]
Abstract
AIM Asthma is one of the most common chronic paediatric diseases worldwide and affects different dimensions of health-related quality of life. This study tested the feasibility and convergent validity of using the EQ-5D-Y instrument on children and adolescents with asthma. METHODS A cross-sectional design was chosen, and children with asthma, aged from 8 to 16 years, were recruited from clinics in Stockholm, Sweden. To test convergent validity, the EQ-5D-Y instrument was combined with the Paediatric Quality of Life Questionnaire. RESULTS The EQ-5D-Y proved feasible as nearly 96% of the 94 respondents completed all items on the questionnaire. High and moderate correlations between the two instruments were found for the dimensions of 'doing usual activities' and 'activity limitations' and for 'having pain or discomfort' and 'symptoms'. The visual analogue scale of the ED-5D-Y correlated with the Paediatric Quality of Life Questionnaire total score and the self-rated health question. The dimensions on the EQ-5D-Y with most reported problems were 'usual activities', 'pain or discomfort' and 'worried, sad or unhappy'. CONCLUSION The EQ-5D-Y instrument seemed to provide feasibility and convergent validity for measuring health-related quality of life in children and adolescents with asthma.
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Affiliation(s)
- Sofi Bergfors
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre; Karolinska Institutet; Stockholm Sweden
- Stockholm County Council; Health Care Services; Stockholm Sweden
| | - Mimmi Åström
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre; Karolinska Institutet; Stockholm Sweden
- Stockholm County Council; Health Care Services; Stockholm Sweden
| | - Kristina Burström
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre; Karolinska Institutet; Stockholm Sweden
- Stockholm County Council; Health Care Services; Stockholm Sweden
- Department of Public Health Sciences; Equity and Health Policy Research Group; Karolinska Institutet; Stockholm Sweden
| | - Ann-Charlotte Egmar
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre; Karolinska Institutet; Stockholm Sweden
- The Red Cross University College; Stockholm Sweden
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Francisco B, Ner Z, Ge B, Hewett J, König P. Sensitivity of different spirometric tests for detecting airway obstruction in childhood asthma. J Asthma 2014; 52:505-11. [PMID: 25375906 DOI: 10.3109/02770903.2014.984842] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study was to compare different measures of airflow obstruction by spirometry in childhood asthma. The objectives were; (a) to compare sensitivity of large airway tests (FEV1 and PEFR) with tests at low lung volumes (small airways) (FEF25-75, FEF50 and FEF75); (b) compare within each group which individual tests are more sensitive. METHODS This was a retrospective analysis of 2307 spirometry tests performed during outpatient visits on 821 doctor-diagnosed asthma patients aged 6-18. Tests were deemed acceptable if they were acceptable and repeatable by American Thoracic Society (ATS) criteria. RESULTS In mild obstruction, FEV1 detected 6.8% abnormal tests while FEF75 detected 33% (p < 0.0001). In more severe obstruction, the difference was more obvious (FEV1 14.8%; FEF75 71%). Tests at low lung volumes (small airway tests) were also more sensitive than PEFR. Within groups, FEV1 was more sensitive than PEFR in the large airway tests and FEF75 was more sensitive than FEF25-75 and FEF50 among the tests at low lung volumes (small airway tests). The FEV1/FVC ratio correlated more closely with tests at low lung volumes (small airway tests), than with large airway tests. CONCLUSIONS (1) Tests at low lung volumes (small airway tests) are more sensitive than large airway tests; (2) Within groups, the FEV1 is better than PEFR and FEF75 is better than FEF25-75 or FEF50.
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Affiliation(s)
- Benjamin Francisco
- Department of Child Health, University of Missouri-Columbia , Columbia, MO , USA and
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Mikalsen IB, Halvorsen T, Øymar K. Blood eosinophil counts during bronchiolitis are related to bronchial hyper-responsiveness and lung function in early adolescence. Acta Paediatr 2014; 103:86-92. [PMID: 24117779 DOI: 10.1111/apa.12432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/06/2013] [Accepted: 09/24/2013] [Indexed: 11/28/2022]
Abstract
AIM To assess whether inflammatory markers measured in urine and blood during acute bronchiolitis in infancy were associated with asthma, lung function, bronchial hyper-responsiveness (BHR) and atopy at 11 years of age. METHODS We included 105 children hospitalised for bronchiolitis during their first year of life. At hospitalisation, urinary (U-) eosinophil protein X, U-leukotriene E4 , U-prostaglandin 9α, 11β-PGF2 and blood eosinophil counts were measured. Ninety-five children (90%) were available for follow-up at 11 years of age. RESULTS At follow-up, higher blood eosinophil counts obtained during bronchiolitis were observed in the group with asthma than in the group without asthma (median 0.27 versus 0.09 × 10(9) /L, respectively, p = 0.048). By regression analyses, blood eosinophil counts during the acute bronchiolitis were positively associated with BHR (p = 0.006) and negatively associated with forced expiratory volume in first second (p = 0.025) at 11 years of age. None of the other inflammatory markers were associated with asthma, lung function, BHR or atopy at 11 years of age. CONCLUSION Eosinophil inflammation during bronchiolitis may have a long-term impact on lung function and airway responsiveness. The associations could be related to virus-host interactions during bronchiolitis or to predisposed children.
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Affiliation(s)
| | - Thomas Halvorsen
- Department of Clinical Science; University of Bergen; Bergen Norway
- Department of Paediatrics; Haukeland University Hospital; Bergen Norway
| | - Knut Øymar
- Department of Paediatrics; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
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